Alignment for Progress: A National Strategy for Mental Health and Substance Use Disorders
It’s time for a meaningful national conversation about mental health and substance use care. We must remove the barriers to equitable and available coverage for these conditions so people can get the help they need.
Welcome To The National Strategy
Want to understand more about the importance of building a National Strategy for Mental Health & Substance Use Disorders?
How Content Is Organized and How Best to Search/Sort the Recommendations
The National Strategy recommendations are organized by category, with impacted populations and topical areas providing additional nuance and the ability to narrow a search. We have also included the option to search recommendations by the relevant House and Senate committees of jurisdiction.
Recommendation Selection Methodologies and Criteria
After conducting a thorough review of the federal policy landscape, The Kennedy Forum team created this first-of-its-kind compilation of policy recommendations needed to transform our mental health and substance use systems. The recommendations have been sourced and vetted from numerous organizations, advocates, and experts across the country in order to capture a robust set of recommendations for lawmakers and federal agencies to act on.
All National Strategy Recommendations
These featured recommendations are highlighted based on their importance in beginning the national movement towards better care for everyone.
Require coverage of early interventions for serious mental illness
Congress should pass legislation requiring all public and private health insurance to cover evidence-based early interventions for serious mental illness and should direct the Department of Health and Human Services to create a national strategy to ensure delivery of these interventions.[1]
Serious mental illness (SMI) is a mental, behavioral, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities.[2] Approximately 14.1 million adults in the United States (5.5 percent of all U.S. adults) have an SMI.[2] Young adults aged 18 to 25 years have the highest prevalence of SMI. However, a lower percentage of these individuals receive mental health treatment than older adults,[2] emphasizing the importance of early interventions for SMI.
Evidence-based early interventions for SMI, including programs that deliver coordinated clinical and supportive services early in the course of SMI onset, are effective[1] and could help delay or prevent loss of function and allow those with SMI to manage problems before they become disabling.[3] However, many programs and emerging early interventions for SMI are not appropriately covered.[1] The Centers for Medicare and Medicaid Services, which oversees Medicaid, the single largest payer of mental health and substance use disorder services in the country,[3] can play a particularly important role in financing, disseminating, and scaling life-changing interventions.
Topics
Pass the Behavioral Health Crisis Care Centers Act
Congress should pass the Behavioral Health Crisis Care Centers Act, which would provide grant funding for states, cities and counties, and tribal governments to establish, operate, and expand one-stop crisis facilities and wrap-around services.[1][2][3] Additionally, Congress should require the Centers for Medicare and Medicaid Services (CMS) to establish a bundled payment under the Outpatient Prospective Payment System (OPPS) for crisis stabilization services for Medicare beneficiaries in crisis to cover up to 23 hours of crisis stabilization services.[4] CMS should also publish a report examining options for providing Medicare coverage of crisis stabilization services furnished by non-hospital providers that cannot bill Medicare under the OPPS.[4]
Crisis facilities are critical for providing stabilization services, short-term care services, and helping transition individuals with MH/SUD to any needed long-term treatment.[3] Unfortunately, MH/SUD crisis care is inconsistent and inadequate, and crisis centers are underfunded, leaving gaps in stabilization services.[3][5] The Behavioral Health Crisis Care Centers Act would increase funding for the establishment, operation, and expansion of crisis facilities and close gaps in services for individuals in MH/SUD crisis.[1][2][3]
About one in four Medicare beneficiaries has a MH/SUD. While OPPS covers some in-patient and out-patient MH/SUD services, and some medications, there are limits in coverage and reimbursement.[6][7] CMS has proposed OPPS updates for 2024 that would cover intensive outpatient MH/SUD services, which is similar to partial hospitalization services. However, crisis stabilization services are still not covered, including screenings and assessments for a MH/SUD crisis.[8] To address this gap, CMS should develop a bundled payment under OPPS that would cover the full range of stabilization services and report on options for covering crisis care provided by non-hospital providers. In late 2022, a bipartisan group of Senate Finance Committee members supported requiring such a bundled payment and report.[4]
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Ensure access to non-emergency medical transportation
Congress should ensure access to Non-Emergency Medical Transportation (NEMT) benefits so they are available to all individuals enrolled in state Medicaid programs while also expanding the types of transit that may be qualified for coverage.[1][2]
Approximately 3.6 million Americans do not obtain medical care because they lack transportation.[3][4] Inequitable access to transportation perpetuates disparities in access to health care and highlights the importance of transportation as a critical social determinant of health.[1][5] For adults without access to transportation, one in five forgo necessary health care services, including for mental health and substance use disorders (MH/SUD), which can interfere with consistent health care, create cumulative deficits in patient treatment, and negatively affect long-term health outcomes.[1][6][7][8] Individuals who are Black or Latino, have low family incomes, have public health insurance, or have a disability are more likely to skip care because of transportation barriers.[1]
Public transportation expansion improves access to health care, especially for people who live in urban areas; are Black, Hispanic/Latinx, or elderly; or have disabilities or low incomes.[1][2][5] NEMT is a Medicaid benefit that delivers people who lack transportation to necessary but non-emergent medical appointments, which commonly include MH/SUD treatment.[2][9][10] Improved access to NEMT for Medicaid beneficiaries results in cost savings for preventative services and treatment for chronic conditions.[2] While state Medicaid programs are required to provide NEMT benefits, administration and reimbursement varies considerably across states and some states have previously carved out the benefit through waivers.[1][2] Congress should require uniform access to NEMT for all eligible individuals covered by Medicaid.
Topics
Pass the Housing Fairness Act
Congress should pass the Housing Fairness Act to fully fund nationwide fair housing efforts and increase funds for the Fair Housing Initiatives Program, which provides grants to fair housing organizations to assist people who have been victims of housing discrimination.[1][2][3]
Housing insecurity, which includes lack of affordable housing, overcrowded living conditions, and homelessness [4], is a critical social determinant of health.[5] Social Determinants of Health (SDOH) are nonmedical factors in the environments where people are born, grow, work, live, and age that affects a wide range of health, functioning, and quality-of-life outcomes and risks.[6][7][8] Housing insecurity exposes individuals and families to increased stress and negatively affects mental and physical health.[4][9][10] Mental health and substance use disorders (MH/SUDs) impact a person’s ability to obtain or maintain housing, especially when faced with discrimination.[5]
The Fair Housing Act protects people from discrimination based on race, color, national origin, religion, sex, gender identity, sexual orientation, familial status, or disability when they are renting or buying a home, applying for a mortgage, seeking housing assistance, or engaging in other housing-related activities.[11] The number of housing discrimination complaints increased significantly in recent years.[12][13] Despite protections, people with MH/SUDs still face discrimination when searching for housing or requesting reasonable accommodations to provide equal opportunity in housing-related issues.[14][15][16]
Housing discrimination trends underscore the need for increased funding to support fair housing efforts.[13] Congress should pass the Housing Fairness Act to address discriminatory practices that affect those with disabilities, including MH/SUDs.
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Extend Medicaid coverage for housing support
Congress should extend Medicaid coverage to cover evidence-based housing support programs and other supportive services.[1] This could include allowing Medicaid to reimburse housing authorities for training and education about housing insecurity,[2] providing incentives in Medicaid funding to coordinate comprehensive support for housing placements,[2], and allowing states to fund transitional housing for individuals experiencing homelessness after leaving an institutional setting.[3]
Housing insecurity, which includes lack of affordable housing, overcrowding living conditions, and homelessness,[4][5] exposes individuals and families to increased stress, negatively impacting mental and physical health.[4][6][7] Mental health and substance use disorders (MH/SUDs) impact a person’s ability to obtain or maintain housing, especially when faced with discrimination.[5] Research overwhelmingly demonstrates that supportive housing—including Housing First[8][9]—improves individual outcomes, enhances communities, and saves public dollars.[1]
The Centers for Medicare and Medicaid Services issued updated guidance on Medicaid waivers, allowing states to use Medicaid funding to support housing expenses like rent and temporary housing.[10] Rent subsidies provided to individuals experiencing homelessness were found to improve reported mental health and reduce both emergency department visits and use of crisis stabilization services.[10] Congress should allow Medicaid to reimburse housing authorities for training and education about housing insecurity,[2] provide incentives in Medicaid funding to coordinate comprehensive support for housing placements,[2], and allow states to fund transitional housing for individuals experiencing homelessness after leaving an institutional setting (e.g., inpatient psychiatric hospital), providing a stable transition to permanent supportive housing.[3]
Topics
Ensure perinatal and postpartum mental health screenings
The Substance Abuse and Mental Health Services Administration (SAMHSA) and the United States Preventive Services Task Force (USPSTF) should issue recommendations on screening for suicide risk in depression screeners for perinatal and postpartum periods. The Health Resources and Services Administration (HRSA) should update its Women’s Preventive Service Guidelines to incorporate maternal mental health screening and intervention.
Pregnant and postpartum women have alarming rates of depression and anxiety. Over 15 percent experience anxiety or depression in the perinatal period, and 20 percent do during the postpartum period.[1] In the United States, the estimated prevalence of major depressive disorder in the postpartum period ranges from 9 percent among pregnant women to 37 percent at any point in the first year postpartum.[2] Perinatal mental health disorders are the most common comorbidity of pregnancy, and suicide is the leading cause of death among pregnant and postpartum women.[3] Yet, mental health disorders are the most underdiagnosed obstetric complication.[4]
The American College of Obstetricians and Gynecologists recommends postpartum follow-up care, including screening for depression and anxiety, for all postpartum women.[5] However, no major federal agency has done the same.
HRSA established the Women’s Preventive Services Guidelines in 2011 based on recommendations from a study by the Institute of Medicine that was commissioned by the Department of Health and Human Services. In 2016 and again in 2021, HRSA awarded the American College of Obstetricians and Gynecologists a cooperative agreement, the Women’s Preventive Services Initiative (WPSI), to convene clinicians, academic researchers, and consumer health professional organizations to develop recommendations for updated guidelines. Currently, the WPSI recommends screening for anxiety in adolescent and adult women, including pregnant and postpartum women but does not detail optimal screening intervals, and it does not recommend mental health screening for depression.[6] Additionally, the USPSTF recommends clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions but does not recommend screening for all pregnant and postpartum people.[7] Under the Affordable Care Act, USPSTF recommendations that receive an “A” or “B” must be covered without patient cost-sharing, which increases access to these services.
These guidelines should be updated to incorporate maternal health screeners for depression and suicidality in the perinatal and postpartum period.